BIDMC researchers looks at impact of patient-to-physician messaging

BOSTON - Email has become one of the most widespread forms of communication, with its streamlined interactions benefiting both businesses and individuals. With the advent of secure patient web portals and the faith that online access has the potential to improve care, the medical industry is slowly catching up.

And while it may take time before it's known what impact email exchanges might have on patients and their care, a new study from Beth Israel Deaconess Medical Center (BIDMC) offers some early insights into the effects on doctors, suggesting that reimbursement models and physician workflow may need to adjust to accommodate message management.

The results were published online in October in Health Affairs.

"BIDMC was one of the first hospitals in the country to create a patient web portal providing a secure platform for patients to view parts of their medical record and send emails to their clinicians," says lead author, Bradley Crotty, MD, Division of Clinical Informatics. "The portal became available in 2000, so we were able to take a 10-year look at the data and examine the email traffic resulting from this new use of technology."

From 2000-2010, nearly 50,000 patients enrolled in BIDMC's patient portal, representing about 23 percent of all patients cared for in the system.

"During the study period we saw a nearly threefold increase in email traffic between patients and doctors," says Crotty. But, he says the driver of the increase appeared not to be individual patients sending more messages, but rather more patients signing on to the portal.

"We saw that over time as patients moved through an early adopter phase and settled in to the idea of communicating this way, the overall number of messages per patient didn't continue to rise, but plateaued over time. However, as more patients enrolled in the portal, physicians' inboxes increased."

The bottom line is that overall, patients didn't message more over time. Still, Crotty found that some doctors exchanged more email than others. Primary care doctors, for example, represented only 40 percent of doctors in the system, but received 85 percent of the email traffic.

"Surveys have shown that patients desire the ability to communicate with their doctors using email, and on face value it seems to be a good idea," says Crotty. "There's a lot of efficiency in being able to send an email and get a response. That type of exchange has the potential to be more respectful of patient's time and possibly the doctor's time too."

Additionally, phase two of the federal program, known as "meaningful use," which is administered by the Office of the National Coordinator for Health Information Technology, includes efforts to improve usage of the patient portals. To receive incentives in phase two of meaningful use, medical providers must meet a threshold of exchanging at least one secure email with five percent of patients within a 90-day window.

"There's been some question about whether that's a high threshold," said Crotty. "But in looking at the data, it appears to be reasonable. At BIDMC, 8.4 percent of the health system's patients sent at least one message to their physician in 2010."

Meaningful use literature cites research demonstrating, among other things, that secure messaging can help improve patient adherence to treatment plans, which, in turn, can reduce hospital readmission rates.

"There's good reason to believe that technology can help improve care," says Bruce Landon, MD, Professor in the BIDMC Division of General Medicine and Primary Care and the Department of Health Care Policy at Harvard Medical School. "Secure messaging can help maintain the doctor/patient relationship outside of the office, aid in patients getting clarity about medical concerns and possibly even play a role in lowering healthcare costs."

But, Crotty, Landon and colleagues ask, in a fee-for-service model of care, how do doctors get reimbursed for email time? And as the healthcare industry moves toward managed care models, where email exchanges will likely become an increasingly more important tool, how can doctors better incorporate email exchanges into the flow of their already busy work days?

"We're convinced that technology has an important place in healthcare delivery and that email between clinicians and patients will remain an essential element even as care models move forward," says Crotty. "But it may require some policy changes and will most certainly involve adjusting the doctor's day, building in time going forward to meet patient demand for email communication."

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Beth Israel Deaconess Medical Center is a patient care, teaching and research affiliate of Harvard Medical School, and currently ranks third in National Institutes of Health funding among independent hospitals nationwide.

BIDMC is in the community with Beth Israel Deaconess Hospital-Milton, Beth Israel Deaconess Hospital-Needham, Beth Israel Deaconess Hospital-Plymouth, Anna Jaques Hospital, Cambridge Health Alliance, Lawrence General Hospital, Signature Healthcare, Beth Israel Deaconess HealthCare, Community Care Alliance, and Atrius Health. BIDMC is also clinically affiliated with the Joslin Diabetes Center and Hebrew Senior Life and is a research partner of Dana-Farber/Harvard Cancer Center. BIDMC is the official hospital of the Boston Red Sox. For more information, visit http://www.bidmc.org.

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